Sunday, January 6, 2013

TB: the Emergency is that We Have Failed, Time for a Different Approach

The English Daily Mail is not a source I would usually turn to for articles about global health issues, but the English MP Peter Hain does have some interesting remarks to make about TB. Following the government's decision to postpone mass culling of badgers to cut transmission of bovine TB to cattle, Hain reminds us that human TB kills about 1.4 million people every year.

Hain also mentions the issue that excites the pharmaceutical industry the most: drug-resistant strains of TB, which are developing and spreading rapidly. If ever there were a demonstration of the foolishness of believing that health was just a matter of fighting disease and that fighting disease is just a matter of throwing drugs at a handful of headline-grabbing diseases, TB is one.

There have been TB eradication programs around for decades and it is the failure of these programs to do any more than throw drugs at people that allows resistance to develop so readily. TB could have been contained a long time ago. But health is not just a matter of fighting disease and TB eradication (or HIV eradication, or any other disease) is not just a matter of drugs.

For a start, people live in appalling conditions. TB spreads rapidly in appalling living conditions, just as water-borne diseases spread rapidly among people who have little or no access to clean water and good sanitation. As long as people live in such conditions, they will continue to suffer from and die from diseases, many of which are preventable and/or treatable. Leaving people in their current conditions means that throwing drugs at them will be of little benefit; for every vaccine they receive, there are hundreds, perhaps thousands of other diseases they can suffer and die from.

Then there are people's working conditions. Hain notes that some of the worst TB epidemics are in South Africa's gold, diamond and coal mining areas, which are said to be responsible for 760,000 new cases of TB every year and the highest death rates for TB in the world. The conditions in which miners work are ideal for the spread of TB. As migrant laborers, most of them return to their families frequently, and they risk spreading TB to anyone with whom they come into contact.

According to Hain, a "migrant worker with TB will typically spread the infection to 10 to 15 other people each year that he’s sick". (Compare this to the 1.2-1.4 people to whom a HIV positive person will typically transmit the virus.) Worse still, "When he returns to his home community, he may not have access to health services capable of putting patients through the necessary six months of TB treatment". Though TB sometimes attracts enough funding for 'treatment' to be free to many people, drugs alone are generally not enough.

The living and working conditions people experience are not conducive to lengthy and expensive drug regimes. Treatment interruptions and treatment failures can quickly give rise to resistant strains of TB developing, which can also be transmitted to others. As resistant TB can be up to 100 times more expensive to treat than non-resistant strains, many will die of the disease. And because it is so readily transmitted, others will be infected with this resistant strain, also.

That's the bit that makes pharmaceutical companies so happy. There's no doubt that they will make a lot more money out of resistant TB. But one of the reasons throwing drugs at the problem does not work is because living and working conditions are not generally addressed by TB eradication programs. Most people don't have access to the sort of health services that will ensure they receive everything they need to clear them of TB. But most also live in conditions where they are highly susceptible to transmitting TB and to being infected, or reinfected, with TB and resistant TB.

Mine owners are not called upon to make conditions healthier. Western buyers of South African raw materials are not keen to increase their costs. The 'economy' of South Africa may depend on mining revenue, but unless that is translated into better living and working conditions for miners, TB and other diseases are not just going to disappear. Good for Big Pharma, not so bad for wealthy South Africans, but not so good for ordinary South Africans.

Hain is incorrect if he assumes that a thriving mining sector results in a stronger economy and that this results in better healthcare systems. The TB epidemic is costing the country a lot of money. So it may seem like a good investment to throw drugs at those with TB. But it's not just healthcare systems that are lacking, it's also education, water and sanitation, habitation and working conditions that are making and keeping people sick.

Hain's suggested approach sounds good, but it is inaccurate to say that an emergency response is needed. Poor living and working conditions mean that emergencies frequently arise, do a lot of damage and can not easily be remedied. But lack of health structures, health personnel, infrastructure and other things mean that TB and other diseases can not be eradicated.

Even ridiculous programs that consist of little more than showering people with drugs could do a lot of good, but not if other conditions are not improved first. There's little to be gained from eradicating one disease only for people to suffer from and die from other diseases, particularly resistant versions of more easily eradicated diseases.

TB, like HIV, is not an emergency in the way that a hurricane or tsunami is. These epidemics result from the conditions in which people live. Massive epidemics are a consequence of most people living in terrible conditions. These are long term trends, many people have never experienced anything but poverty and struggle. Perhaps an emergency can be declared in response to endemic diseases, one by one, as seems to be the favored approach by international institutions. But why not address the conditions in which people live and work, the rights they are denied, the determinants of health and the rest?

The emergency is that we have tried and failed to eradicate some of the most serious diseases by addressing them one by one and merely throwing drugs at them. The emergency is that realizing there is a problem and setting up institutions in wealthy countries is not enough. Countries like South Africa need health systems, education, infrastructure and decent living and working conditions. Addressing TB on its own will continue to fail unless other development areas are also addressed. If there is an emergency, it is that we have known all this for decades and have systematically failed to act on that information.

Peter Hain is not wrong, but we don't need to address basic health and social services and various other problems in order to eradicate TB, we need to do all these to eradicate any disease. We also need to address these issues to ensure that people enjoy good health, which is not merely the absence of disease. Of course, these are also conditions under which diseases can be controlled, and that includes TB. Throwing drugs at people and sending them back to the conditions in which diseases thrive, what we are doing right now, is clearly not the right approach.

[For more about non-sexual HIV transmission through unsafe healthcare, see the Don't Get Stuck With HIV site.]


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